Sore Throat After Ingestion of an Unknown Substance

Answer. B. Chronic pneumomediastinum and subcutaneous emphysema

The patient’s imaging shows moderate pneumomediastinum, more prevalent superiorly. There is extensive subcutaneous emphysema within the base of the neck extending into the retropharyngeal and prevertebral soft tissues. The most likely etiology is chronic pneumomediastinum and subcutaneous emphysema.

We considered several differential diagnoses, including esophageal perforation causing subcutaneous air, streptococcal tracheitis due to the positive strep test, and anatomical trauma to the upper airway as a possible cause of subcutaneous air. Each of these considerations was addressed and ruled out in the workup through appropriate consultations with specialists.          

Treatment and management. We admitted the patient for further workup and management. He was given 1.2 million units of intramuscular penicillin G injection for his strep throat. For his acute kidney injury, he had an appropriate response to IV fluid resuscitation. He underwent gastrografin esophagram to rule out esophageal perforation, which showed the esophagus had normal caliber and no leakage.

We consulted with pulmonologists, who recommended monitoring. An arterial blood gas test was within normal limits. We also consulted with otolaryngology who recommended flexible fiberoptic laryngoscopy, which showed no masses, normal vocal cords, normal epiglottis, and clear piriformis sinuses. The patient was extensively counseled on both vaping and other substance use. During these conversations, it was revealed that he typically performs a Valsalva maneuver while inhaling, reporting that this increases the “high” he experiences. After discussions with pulmonologists, it was believed that this was the best explanation for his pneumomediastinum, making it more chronic than acute in etiology.

Smoking cessation assistance with nicotine replacement products was offered, which the patient declined. He was also encouraged to seek treatment for other substance abuse. Information regarding a local recovery group for people struggling with substance abuse was provided to him before discharge. We scheduled him for outpatient follow-up with pulmonology and to establish care with a primary care doctor. He was scheduled for his transition of care visit with a clinic specifically geared to and located near shelters in town that assisted those currently unhoused.

Outcome and follow-up. The patient had a follow-up 1 week after discharge with internal medicine outpatient for transition of care. The culture from the ulcer in his mouth returned positive for polymicrobial gram positive cocci and gram-negative bacilli. These are common bacteria found in the oropharynx, and the patient had denied any current sore throat and dysphagia. He had received the penicillin G injection during his hospital stay and has been eating and drinking well. Although the patient had continued to smoke one pack per day after his discharge, he denied alcohol use. During his transition of care visit, he was counseled on avoiding inhaling substances.  

Discussion. Pneumomediastinum is defined as the presence of air within the mediastinum. The condition is generally separated into traumatic and spontaneous categories. Traumatic pneumomediastinum occurs because of blunt chest wall trauma or due to various esophageal or tracheal procedures. Spontaneous pneumomediastinum is much rarer and occurs secondary to non-traumatic causes that typically increase intrathoracic pressure. This is much more common in men between the second and fourth decades¹ and includes emesis, cough, defecation, exercise, and inhalational drug use. It can also occur in other populations because of prolonged labor or neonatal respiratory distress syndrome.²

Spontaneous pneumomediastinum is typically associated with a benign clinical course that can be managed and followed as an outpaitent. Pre-existing lung diseases can predispose to this condition, including asthma, interstitial lung disease, and emphysema. Although most people who are found to have this condition are hospitalized, their admission diagnosis is typically for an unrelated cause, and the pneumomediastinum is an incidental finding on other imaging. However, it is important to rule out concomitant pneumothroax.

This case specifically discusses pneumomediastinum because of inhalational drug use. Barotrauma, including pneumomediastinum, subcutaneous emphysema, and pneumothorax are rare, but well-documented complications of this condition. Indeed, pneumomediastinum is a well-known complication of substance abuse by inhalation. There are case reports of pneumomediastinum caused by cocaine,⁴ opioids,⁵ marijuana,⁶ and vaping.⁷ Also, pneumomediastinum is reported with cannabinoid hyperemesis syndrome.⁸

Valsalva maneuvers are associated with both vomiting and with inhalation. Although performing Valsalva while inhaling increases one’s “high”, when this continues to occur over time, it allows air to accumulate in the tissues slowly thus not causing any symptoms. In addition, the course tends to be benign and self-resolving after the cessation of substance abuse.

Conclusion. This case is an example of the myriad presentations of substance use. Furthermore, it illustrates how each encounter with the medical system is an opportunity to provide substance counseling and refer for treatment.

AUTHORS:
Debbie Hoang, DO ¹ • Hannah Meyers, MD ¹ • Nathan Bradford, MD ¹

AFFILIATIONS:
¹AnMed Health Family Medicine Residency Program, Anderson, SC

CITATION:
Hoang D, Meyers H, Bradford N. Sore throat after ingestion of an unknown substance. Consultant. Published online May 15, 2025. DOI: 10.25270/con.2025.05.000002

Received February 20, 2024. Accepted December 20, 2024.

DISCLOSURES:
The authors report no relevant financial relationships.

ACKNOWLEDGEMENTS:
None.

CORRESPONDENCE:
Nathan Bradford, MD, AnMed Health Family Medicine Residency Program, 2000 East Greenville St., Suite 3700 Anderson, SC (nbradfor@anmed.org)

References

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